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NTcommunity2022-05-20

Inquest into the death of Reginald Roy

16y · Male·Consequences of high voltage electrical injury due to mental disorder/psychosis

Reginald, a 16-year-old Aboriginal boy with first episode psychosis, intellectual disability, and fetal alcohol spectrum disorder, was admitted to the Youth Inpatient Unit and improved significantly with inpatient care. …

psychiatrypaediatricscommunicationsystemaripiprazole
VIC2022-05-17

Finding into death of Cameron Richard Plant

52y · Male·hanging

Cameron Richard Plant, aged 52, died by hanging in hotel quarantine on 11 April 2020. This case highlights critical failures in mental health screening, welfare monitoring, and escalation procedures. Recent personal stre…

systemcommunication
VIC2022-05-17

Finding into death of Cameron Richard Plant

52y · Male·Hanging

Cameron Richard Plant, a 52-year-old male, died by hanging in hotel quarantine on 11 April 2020, shortly after returning to Australia from Dubai. He was experiencing significant psychosocial stressors including marriage …

psychiatrypublic healthcommunicationsystem
VIC2022-05-16

Finding into death of Marcus Lloyd Adams

44y · Male·Stab wound to the chest

Marcus Lloyd Adams, a 44-year-old man, died from a stab wound to the chest inflicted by his de facto partner during a physical altercation at a caravan park on 20 September 2019. There was no prior history of family viol…

forensic medicineemergency medicinedelaymethamphetamine
VICaged care2022-05-11

Finding into death of Gwenyth Evelyn Miles

88y · Female·Multisystem organ failure in the context of exposure, humeral fracture, and clin…

An 88-year-old woman with Alzheimer's dementia resident in aged care left the facility undetected on a hot day and collapsed 800-900 metres away with a humeral fracture. She died nearly two months later from multisystem …

geriatric medicineforensic medicinesystemdelay
VIChospital2022-05-09

Finding into death of Robert Albert Burns

75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…

A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…

colorectal surgeryintensive carediagnosticdelay
VICmental health2022-05-02

Finding into death of Stuart Brant Garten

34y · Male·Hypoxic/ischaemic brain injury following resuscitated cardiac arrest and hanging

Stuart Brant Garten, a 34-year-old man with complex psychiatric diagnoses including borderline personality disorder, post-traumatic stress disorder, and schizophrenia, died by hanging in the courtyard of a secure extende…

psychiatryintensive carecommunicationsystemrisperidone
TAS2022-04-29

Coroner's Finding: Lavoipierre, Andre Marc

41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …

Andre Marc Lavoipierre, age 41, died on 26 June 2019 from exsanguination due to internal bleeding (ureter-iliac artery fistula or steady renal/bladder bleed). He fell at his supported residential unit on the morning of d…

psychiatrygeneral practicecommunicationdelayfluoxetine
VIChome2022-04-29

Finding into death of Mr S

20y · Male·Mixed drug toxicity (ethanol, etizolam, flubromazolam, cocaine)

Mr S, a 20-year-old, died from mixed drug toxicity after consuming counterfeit alprazolam tablets containing undeclared benzodiazepines (etizolam and flubromazolam) along with alcohol and cocaine. He was found unresponsi…

toxicologyforensic medicinedelayalcohol
QLDcommunity2022-04-28

Mathieson, Troy James and Morton, Hughie Kirk Douglas

23y · Male·Drowning/immersion

Troy Mathieson (23) and Hughie Morton (21) drowned in flood waters while entering a culvert to avoid police detention during extreme flooding in Townsville on 4 February 2019. The men entered a flooded drain after being …

delaycommunicationalcohol
VIChome2022-04-27

Finding into death of Leonardo Antonio Biancofiore

61y · Male·Neck injuries in the setting of a dog attack

Leonardo Biancofiore, 61 years old with longstanding syringomyelia requiring mobility aids, died from massive neck injuries sustained in a dog attack by his American Staffordshire Terrier at his home. The attack occurred…

emergency medicineforensic medicinesystemcommunication
QLDhospital2022-04-26

Jessen, Tyson Lee

28y · Male·Gunshot wounds of the neck, chest and abdomen

Tyson Jessen, a 28-year-old man wanted for armed robbery in Victoria, was arrested in Queensland and admitted to Ipswich Hospital with cardiac symptoms. While in police custody, he remained under guard in hospital. Senio…

emergency medicinecardiologycommunicationsystemmetoprolol
SAcommunity2022-04-22

Coroner's Finding: Bentley, John James

80y · Male·Dehydration and the effects of heat with contributing Alzheimer's dementia

An 80-year-old man with advanced Alzheimer's dementia disappeared from a respite care facility on a day of extreme heat (39°C) and died from dehydration and heat exposure. Key failures included: (1) relocation of the day…

geriatric medicineemergency medicinediagnosticsystem
SAhome2022-04-21

Coroner's Finding: Rigney, Amber Rose and Mitchell, Korey Lee

Unknown·Amber Rose Rigney: external airway occlusion with compression of the neck; Korey…

Two children, Amber Rose Rigney (6) and Korey Lee Mitchell (5), were murdered on 30 May 2016 by their mother's partner Steven Graham Peet. The Coroner found their deaths were preventable. The children's mother had been u…

paediatricssystemdelayice/methamphetamine
VIC2022-04-19

Finding into death of Mr BB

29y · Male·Multiple injuries sustained in a fall from a height

Mr BB, a 29-year-old male, fatally assaulted his de facto partner Ms AA with a weight plate while she slept, then jumped from a 23-storey building. The relationship, which began in June 2020, progressed rapidly during CO…

general practicepsychologydiagnosticdelay
WAhome2022-04-13

Inquest into the Death of Boris DRLESKI

45y · Male·bronchopneumonia and combined drug toxicity

Boris Drleski, a 45-year-old with treatment-resistant chronic paranoid schizophrenia, antisocial personality disorder, and polysubstance use disorder, died from bronchopneumonia and combined drug toxicity. He was managed…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
SAhospital2022-04-13

Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…

emergency medicinegastroenterologydiagnosticcommunicationparacetamol
NSWhome2022-04-13

Inquest into the death of Tateolena TAUAIFAGA

1y · Female·Blunt head injuries

Tateolena Tauaifaga, a 17-month-old child, died from blunt head injuries when a stolen vehicle pursued by police during a high-risk vehicle intercept (HRVI) crashed through her home's fence into her backyard. Critical fa…

systemcommunication
VIChospital2022-04-11

Finding into death of C J

22y · Male·Hanging

A 22-year-old man with depression, alcohol addiction, and recent significant losses (parents, sister, friend) presented to Frankston ED on 14 January 2018 with active suicidal ideation and a specific plan to hang himself…

emergency medicinepsychiatrycommunicationsystemdiazepam
TAShome2022-04-08

Coroner's Finding: Reardon, Michael Wayne

69y · Male·right lower lobe pneumonia as a complication of diabetes mellitus

Michael Wayne Reardon, aged 69, died at home from right lower lobe pneumonia as a complication of diabetes mellitus. He was entirely dependent on his siblings for care, with his sister Julie administering medications. He…

general practicepsychiatrydelaysystem

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